Descending threshold for ascending aortic aneurysmectomy: Is it time for a "left-shift'' in guidelines?
Descending threshold for ascending aortic aneurysmectomy: Is it time for a "left-shift'' in guidelines?
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DOI：
10.1016/j.jtcvs.2018.07.114
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发表时间：
2019-01-01
影响因子：
6
通讯作者：
Elefteriades, John A.
中科院分区：
文献类型：
--
作者：
Ziganshin, Bulat A.;Zafar, Mohammad A.;Elefteriades, John A.
目前关于胸主动脉疾病管理的指南建议当升主动脉达到5.5 cm时进行置换。最近出现的数据表明，该标准可能需要向左移动，这意味着建议对主动脉尺寸较小的患者进行手术。支持指南中需要进行大幅调整的数据包括：（1）关于5 - 6 cm升主动脉瘤自然史的新的和更细粒度的数据，显示存在2个铰链风险点-一个在5.25 cm，另一个在5.75 cm;（2）主动脉夹层形成前的主动脉直径比夹层形成后的主动脉直径至少小7 mm;（3）影像学评估的半自动中心线方法的出现似乎低估了真实的升主动脉大小;（4）目前的主动脉手术非常安全，其益处大于相关风险;（5）通过高通量下一代测序进行的基因检测可识别导致较小主动脉大小的主动脉灾难的遗传缺陷;（6）家族性主动脉夹层的发生表明，无论主动脉瘤大小如何，主动脉夹层患者的家庭成员都应该接受手术。
Current guidelines on the management of thoracic aortic disease recommend that the ascending aorta be replaced when it reaches the size of 5.5 cm. Recently emerging data suggest that this criterion may need to be shifted to the left, signifying a recommendation to operate on patients with smaller aortic sizes. The data that support the need for a leftward shift in the guidelines include (1) novel and more granular data on the natural history of ascending aortic aneurysm between 5 and 6 cm showing that 2 hinge risk points exist-one at 5.25 cm, and the other at 5.75 cm; (2) aortic diameter before the moment of aortic dissection is at least 7 mm smaller than postdissection aortic size; (3) the advent of a semiautomated centerline method of imaging assessment seems to underestimate true ascending aortic size; (4) aortic surgery in the present era is very safe and its benefits outweigh the associated risks; (5) genetic testing via high-throughput next-generation sequencing identifies genetic defects responsible for aortic catastrophes at smaller aortic sizes; and (6) familial aortic dissection occurrence suggests that family members of an aortic dissection victim who harbor a sizable aneurysm should be operated on regardless of aortic size.